Provider Demographics
NPI:1831590363
Name:JOHNSON, MELANIE RENAE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:RENAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MELANIE
Other - Middle Name:RENAE
Other - Last Name:RIGLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-4200
Mailing Address - Fax:814-375-4232
Practice Address - Street 1:761 JOHNSONBURG RD
Practice Address - Street 2:SUITE #160
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-3483
Practice Address - Country:US
Practice Address - Phone:814-788-8777
Practice Address - Fax:814-788-8770
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056954363AM0700X
PAOA003330363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103146235Medicaid